AAN 2026 | Differentiating migraine, epilepsy, and stroke in overlapping neurologic presentations

Thank you so much for the great question. We are preparing an exciting session at the American Academy of Neurology this year in Chicago, where we go and discuss different neurologic spells with the headache section, epilepsy section, and vascular neurologist sections. I am a vice chair for the headache and facial pain section of the American Academy of Neurology. And I’m so glad that we are talking about it with our colleagues because migraine, epilepsy, and stroke can come as a spell, as an episode. And very often, headache is one of the symptoms of other conditions. So how do we distinguish it? And we know data. For example, epilepsy can come with headache post-ictally in about 20% of cases, according to some literature. And people with stroke, during having a stroke, could have a headache. Generally speaking, a migraine is known for headache being in 95% of cases after other neurologic symptoms. So when people have changes in vision, changes in sensations, sometimes weakness as a neurologic symptom, we do think about where headache fits in this time-wise. Another distinction will be that with migraine, the spread of neurologic symptoms, generally speaking, can be more slow. So if with a seizure, an epileptic seizure, or with stroke, a neurologic condition develops the way that symptoms come very fast after each other. With migraine, generally speaking, which I keep repeating because there is always an exception, it comes more in a slow fashion. People with migraine are more likely to have sensitivity to light and sound. We also take it into consideration. And then we know some known migraine visual changes such as scintillations or this spreading very slowly around visual fields. We call it the evolution of visual symptoms. So there is a lot of art to that, but we also have exciting testing such as imaging and EEG and so on to help clinicians distinguish what is happening in this particular case. When we see a person with overlapping symptoms, it brings me to think about our international classification of headache disorders. Right now, we have ICHD3, and we’re all working as a headache community. And the International Headache Society has a committee led by Dr Goadsby, whom I’m very grateful to be trained in headache medicine as his fellow in the past and mentor even now. And we’re working on the next one. But ICHD3 is something that distinguishes different conditions for us, and with migraine, we have to exclude other conditions that can lead to headache. To exclude those other conditions, we would use imaging, and an example would be MRI for epilepsy, and to do proper testing, we would consider EEG when needed. And this way, we can treat the person appropriately. Now, there are interesting diagnoses and thankfully not very common that definitely have some overlap with things like hemiplegic migraine. Hemiplegic migraine is migraine but with a symptom of weakness and muscular weakness. And some types come with a genetic component and we can do genetic tests, but some we don’t know what gene is responsible for that. And then it could be an overlap in genetics between some genes in migraine and epilepsy. So we cannot rely so far on genetic components. So when a person comes in urgent emergency or in the clinic with new weakness, we do have to exclude epilepsy and we have to exclude stroke at least this time. And then if a person gets diagnosed, we excluded epileptic seizure and we excluded stroke. We can then, if next time it repeats itself and it’s stereotypical and we know it’s hemiplegic migraine, we treat appropriately with very well-known and established treatment for hemiplegic migraine when a person has migraine, which shows with this muscular weakness as one of the components.

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